Failure to Provide Physician-Ordered Food Consistency for Residents with Dysphagia
Penalty
Summary
The facility failed to provide food in the physician-ordered consistency for two residents who required modified diets due to dysphagia. For one resident, meal observations revealed that food items such as beef, vegetables, tomatoes, and bean sprouts were not chopped to the required size, with some pieces exceeding the defined chopped consistency. Multiple staff members, including Certified Nurse Aides and the Infection Prevention Coordinator, confirmed that the food items did not meet the expected chopped consistency, referencing standards such as 'less than one inch by one inch' or 'sugar cube sized.' For another resident, similar issues were observed, with food items on both lunch and breakfast trays being inconsistent in size and not appropriately chopped. The Executive Chef stated that there was no specific reference size for chopped consistency, despite the IDDSI framework defining bite-sized pieces as no larger than 15 mm. These observations and staff interviews demonstrated that the facility did not consistently prepare food according to the prescribed diet modifications for residents with dysphagia.